Jonathan Nover, MBA, RN
Vice President of Nursing | Emergency Services
Mount Sinai Health System, New York City

The problem.

In early July 2024, a nationwide blood culture bottle shortage was announced. At the Mount Sinai Health System, specifically for our eight emergency departments (ED), naturally high utilizers, it was critical to devise contingency plans to reduce utilization and preserve supplies. Since it was evident early on that ED nursing would play a critical role in reducing utilization and waste, it was crucial to understand our current burn rates, utilization rates, contamination rates, and fill volume rates. We would need to recalibrate our blood culture stewardship and check in with our teams to understand workflows and their knowledge baseline about the nationwide shortage.

Discovering a gap in knowledge.

Through varying methods, huddles, “walking the GEMBA” with nursing leaders, epidemiologists, and infection preventionists, and eliciting transparent feedback, we learned very quickly that our ED teams were not all aware of the top reasons for blood culture waste.

A nursing practice alert.

We created a nursing practice alert to highlight several key elements we’d learned . The areas of focus,

(1) Blood Cultures should not be drawn without an order. The nature of the ED setting challenges clinicians to bundle and maximize. It is crucial for us to ensure the multidisciplinary teams were making decisions as a team, using closed loop communication, and aligning clinical orders with practice.
(2) Contamination mitigation and proper technique.
(3) Ensuring blood culture sets are drawn from different sites. Although this is a routine educational competency for our clinical teams, reeducation was conducted by our nursing leaders and educators to strengthen knowledge and technique.
(4) Ensuring adult and pediatric fill volumes are appropriate. The practice alert detailed fill volume rates based on manufacturer guidelines and age. Our team’s transparency enabled us to learn that not all staff were aware that samples were unusable if not filled correctly.

With all quality improvement projects or any change, we always consider the countermeasures and unintended consequences. I was particularly concerned the shortage would impact the gains we made in our new sepsis protocols. On July 19th, 2023, New York State governor Kathy Hochul signed the Non-Patient Specific Orders bill #A6030C- Paulin/S6886 Rivera into law. This legislation enabled registered nurses in New York State to enact predetermined order sets to optimize and hasten patient care. Although our nurses at the Mt. Sinai Hospital System EDs perform non-patient specific nursing protocols based on sepsis triggers, our analysis early on showed that our ED blood culture utilization was not primarily driven by sepsis and our ED non–patient specific nursing sepsis protocols had an 85% positivity rate of being put on the sepsis pathway by a provider. This meant that our nurses were accurately predicting the need to hasten blood cultures at a high enough rate not to halt the program.

A systemwide reduction in blood culture bottle use.

Since the onset of this work, our EDs have seen a 45% reduction in blood culture bottle utilization systemwide. Across ED sites specifically, we have seen an average blood culture reduction range of 25%  to 65%. Although it seems the nationwide blood culture bottle shortage has come to a near end as supply chain confidence is up, under our blood culture stewardship, our ED sites continue to focus on methods to decrease contamination rates, ensure fill volumes are appropriate, decrease waste, and monitor our non-patient specific nursing sepsis 0rders.

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Jill Frick, DNP, RN, CEN
Director of Nursing | Emergency Department
Mount Sinai West

Disseminating the nurse practice alert.

The ED nursing director team was notified of the nationwide blood culture shortage on the first week of July 2024. My immediate response was to examine the nursing role in the utilization of blood culture bottle supply. With our collective input a nursing practice alert was created and disseminated to all the ED nursing directors via our emergency medicine service line. I further disseminated the practice alert through Mount Sinai West specific staff email distribution lists and in huddles. Through education and robust communication, I felt confident that we would be able to reduce blood culture bottle waste. Additionally, we have been monitoring our blood culture contamination rates, fill volumes, and utilization rates with the clinical teams.

Recently, we rolled out our non–patient specific nursing sepsis orders and encouraged utilization to optimize and hasten sepsis care. Thankfully, the blood culture bottle shortage has not negatively impacted this work. We have educational modules for blood culture collection in our online educational platform, which was messaged to the staff to review. Emergency nursing leadership also observes blood culture collection to support technique and as we observe and communicate updates, we also solicit feedback and opportunities.

The value of staff feedback and engagement.

Staff feedback has been valuable. Some nurses have asked for more education on pediatric sepsis to understand the needs and differences in blood culture collection. In addition to our education modules, the nursing practice alert specified age variations in blood culture fill volume which the teams found useful. After the clinical decision support guide was initiated by our physician leadership, there was an increase in multidisciplinary discussions. Conversations seemed to be naturally popping up across the ED, querying if blood cultures were necessary on a case-by-case basis.

Achieving a 30% reduction in culture bottle utilization.

Lastly, our supply chain team has been working closely with the emergency department routinely assessing the par levels of blood culture bottles. Normally we have multiple sets of blood cultures in our supply carts spread across our ED. To manage the shortage, we centralized blood culture storage to the nurses’ station and resuscitation bay. With our collective efforts we have seen a 30% decrease in blood culture bottle utilization, from an average of 17 bottles per day to 12 bottles per day. I am proud of the team at Mount Sinai West ED and their ability to be so agile.

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Ledjan Halollari, MSN, RN
Director of Nursing | Emergency Department
Mount Sinai Brooklyn

Initial steps.

The initial communication was received the first week of July through several pathways. All the ED nursing directors had an emergent huddle with our system VP of nursing for emergency medicine. My immediate response was to gather information about the impact of the shortage and how it would affect the ED and hospital. Our local team met with our supply chain manager to see how many blood cultures we had in our facility storage and then how many we had in our respective units. We then made sure we placed all of our supplies in a single cart next to the nurse in charge desk.

Meeting to assess the shortage impact and nursing role.

I knew that the nursing role in mitigating waste was going to be crucial. As soon as we had enough information and the start of a plan, we huddled with the ED nurses and providers to discuss the nationwide shortage. All agreed this would impact the way we operated for months to come.

Partnering with nursing education.

The next morning we were provided with a nursing practice alert via the emergency medicine service line leadership. We held huddles with our staff and added the practice alert to our daily management board. We partnered with nursing education to reinforce the elements in the practice alert, technique, fill volume, collection, and order requirements. Our physician partners were doing the same by reviewing a change in their ordering practice.

The role of the new sepsis alert protocol.

Additionally, our sepsis alert protocol, which we had started earlier in the year, has been helping us manage the shortage as it ensures that everyone is on the same page regarding the plan of care for a potentially septic patient. The team huddles at the bedside and reviews the plan of care, which includes the need for blood cultures. The review also includes the total number of sets of blood cultures. As a result of the huddles, nursing education, changes in physician ordering parameters, communication between the nurses and providers, and our partnership with supply chain, we have seen a decrease in the utilization of blood cultures in our ED by 65%, with an average of 7 bottles per day versus 20 bottles per day before the shortage announcement. I am proud of the teamwork in this ED and support received from the emergency medicine service line.

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